Initial nutritional management during noninvasive ventilation and outcomes: a
retrospective cohort study.
Terzi N(1)(2), Darmon M(3), Reignier J(4), Ruckly S(5)(6), Garrouste-Orgeas
M(7), Lautrette A(8), Azoulay E(9), Mourvillier B(6)(10), Argaud L(11), Papazian
L(12), Gainnier M(13), Goldgran-Toledano D(14), Jamali S(15), Dumenil AS(16),
Schwebel C(17)(18), Timsit JF(6)(10); OUTCOMEREA study group.
Collaborators: Timsit JF, Azoulay E, Garrouste-Orgeas M, Zahar JR, Adrie C,
Darmon M, Clec'h C, Timsit JF, Alberti C, Ruckly S, Bailly S, Styfalova L,
Vannieuwenhuyze A, Adrie C, Allaouchiche B, Argaud L, Ara-Somohano C, Azoulay E,
Barbier F, Bohé J, Cheval C, Clec'h C, Darmon M, Dumenil AS, Dupuis C, Forel JM,
Gainier M, Haouache A, Jamali S, Khallel H, Lautrette A, Marcotte G, Le Miere E,
Lugosi M, Mourvillier B, Misset B, Moreau D, Mourvillier B, Papazian L,
Planquette B, Souweine B, Schwebel C, Terzi N, Troché G, Thuong M, Thierry G,
Toledano D, Vantalon E, Fournier J, Tournegros C, Bagur S, Adda M, Vindrieux V,
Ferrand L, Kaddour N, Berthe B, Bekkhouche S, Mellouk K, Conrozier S, Theodose
I, Deiler V, Letrou S.
BACKGROUND: Patients starting noninvasive ventilation (NIV) to treat acute
respiratory failure are often unable to eat and therefore remain in the fasting
state or receive nutritional support. Maintaining a good nutritional status has
been reported to improve patient outcomes. In the present study, our primary
objective was to describe the nutritional management of patients starting
first-line NIV, and our secondary objectives were to assess potential
associations between nutritional management and outcomes.
METHODS: Observational retrospective cohort study of a prospective database fed
by 20 French intensive care units. Adult medical patients receiving NIV for more
than 2 consecutive days were included and divided into four groups on the basis
of nutritional support received during the first 2 days of NIV: no nutrition,
enteral nutrition, parenteral nutrition only, and oral nutrition only.
RESULTS: Of the 16,594 patients admitted during the study period, 1075 met the
inclusion criteria; of these, 622 (57.9%) received no nutrition, 28 (2.6%)
received enteral nutrition, 74 (6.9%) received parenteral nutrition only, and
351 (32.7%) received oral nutrition only. After adjustment for confounders,
enteral nutrition (vs. no nutrition) was associated with higher 28-day mortality
(adjusted HR, 2.3; 95% CI, 1.2-4.4) and invasive mechanical ventilation needs
(adjusted HR, 2.1; 95% CI, 1.1-4.2), as well as with fewer ventilator-free days
by day 28 (adjusted relative risk, 0.7; 95% CI, 0.5-0.9).
CONCLUSIONS: Nearly three-fifths of patients receiving NIV fasted for the first
2 days. Lack of feeding or underfeeding was not associated with mortality. The
optimal route of nutrition for these patients needs to be investigated.
DOI: 10.1186/s13054-017-1867-y
PMCID: PMC5707783
PMID: 29187261 [Indexed for MEDLINE]
Respective impact of implementation of prevention strategies, colonization with
multiresistant bacteria and antimicrobial use on the risk of early- and
late-onset VAP: An analysis of the OUTCOMEREA network.
Ibn Saied W(1)(2), Souweine B(3), Garrouste-Orgeas M(4), Ruckly S(1), Darmon
M(5), Bailly S(1)(6), Cohen Y(7), Azoulay E(8), Schwebel C(2), Radjou A(9),
Kallel H(10), Adrie C(11), Dumenil AS(12), Argaud L(13), Marcotte G(14), Jamali
S(15), Papazian L(16), Goldgran-Toledano D(17), Bouadma L(9), Timsit JF(1)(9);
OUTCOMEREA study group.
RATIONALE: The impact of prevention strategies and risk factors for early-onset
(EOP) versus late-onset (LOP) ventilator-associated pneumonia (VAP) are still
debated.
OBJECTIVES: To evaluate, in a multicenter cohort, the risk factors for EOP and
LOP, as the evolution of prevention strategies.
METHODS: 7,784 patients with mechanical ventilation (MV) for at least 48 hours
were selected into the multicenter prospective OUTCOMEREA database (1997-2016).
VAP occurring between the 3rd and 6th day of MV defined EOP, while those
occurring after defined LOPs. We used a Fine and Gray subdistribution model to
take the successful extubation into account as a competing event.
MEASUREMENTS AND MAIN RESULTS: Overall, 1,234 included patients developed VAP
(EOP: 445 (36%); LOP: 789 (64%)). Male gender was a risk factor for both EOP and
LOP. Factors specifically associated with EOP were admission for respiratory
distress, previous colonization with multidrug-resistant Pseudomonas aeruginosa,
chest tube and enteral feeding within the first 2 days of MV. Antimicrobials
administrated within the first 2 days of MV were all protective of EOP. ICU
admission for COPD exacerbation or pneumonia were early risk factors for LOP,
while imidazole and vancomycin use within the first 2 days of MV were protective
factors. Late risk factors (between the 3rd and the 6th day of MV) were the
intra-hospital transport, PAO2-FIO2<200 mmHg, vasopressor use, and known
colonization with methicillin-resistant Staphylococcus aureus. Among the
antimicrobials administered between the 3rd and the 6th day, fluoroquinolones
were the solely protective one.Contrarily to LOP, the risk of EOP decreased
across the study time periods, concomitantly with an increase in the compliance
with bundle of prevention measures.
CONCLUSION: VAP risk factors are mostly different according to the pneumonia
time of onset, which should lead to differentiated prevention strategies.
DOI: 10.1371/journal.pone.0187791
PMCID: PMC5706682
PMID: 29186145 [Indexed for MEDLINE]
Effect of Transfusion on Mortality and Other Adverse Events Among Critically Ill
Septic Patients: An Observational Study Using a Marginal Structural Cox Model.
Dupuis C(1)(2), Garrouste-Orgeas M(3), Bailly S(1), Adrie C(4),
Goldgran-Toledano D(5), Azoulay E(6), Ruckly S(1), Marcotte G(7), Souweine B(8),
Darmon M(9), Cohen Y(10), Schwebel C(11), Lacave G(12), Bouadma L(1)(2), Timsit
JF(1)(2); OUTCOMEREA Study Group.
OBJECTIVES: RBC transfusion is often required in patients with sepsis. However,
adverse events have been associated with RBC transfusion, raising safety
concerns. A randomized controlled trial validated the 7 g/dL threshold, but
previously transfused patients were excluded. Cohort studies led to conflicting
results and did not handle time-dependent covariates and history of treatment.
Additional data are thus warranted to guide patient's management.
DESIGN: To estimate the effect of one or more RBC within 1 day on three major
outcomes (mortality, ICU-acquired infections, and severe hypoxemia) at day 30,
we used marginal structural models. A trajectory modeling, based on hematocrit
evolution pattern, allowed identification of subgroups. Secondary analyses were
performed into each of them.
SETTING: A prospective French multicenter database.
PATIENTS: Patients with sepsis at admission. Patients with hemorrhagic shock at
admission were excluded.
INTERVENTIONS: None.
MEASUREMENTS AND MAIN RESULTS: Overall, in our cohort of 6,016 patients, RBC
transfusion was not associated with death (hazard ratio, 1.07; 95% CI,
0.88-1.30; p = 0.52). However, RBC transfusion was associated with increased
occurrence of ICU-acquired infections (hazard ratio, 2.77; 95% CI, 2.33-3.28; p
< 0.01) and of severe hypoxemia (hazard ratio, 1.29; 95% CI, 1.14-1.47; p <
0.01). A protective effect from death by the transfusion was found in the
subgroup with the lowest hematocrit level (26 [interquartile range, 24-28])
(hazard ratio, 0.72; 95% CI, 0.55-0.95; p = 0.02).
CONCLUSIONS: RBC transfusion did not affect overall mortality in critically ill
patients with sepsis. Increased occurrence rate of ICU-acquired infection and
severe hypoxemia are expected outcomes from RBC transfusion that need to be
weighted with its benefits in selected patients.
DOI: 10.1097/CCM.0000000000002688
PMID: 28906284 [Indexed for MEDLINE]
Potentially modifiable factors contributing to sepsis-associated encephalopathy.
Sonneville R(1)(2), de Montmollin E(3)(4), Poujade J(5), Garrouste-Orgeas
M(3)(6), Souweine B(7), Darmon M(8)(9), Mariotte E(10), Argaud L(11), Barbier
F(12), Goldgran-Toledano D(13), Marcotte G(14), Dumenil AS(15), Jamali S(16),
Lacave G(17), Ruckly S(3), Mourvillier B(5)(3), Timsit JF(5)(3).
PURPOSE: Identifying modifiable factors for sepsis-associated encephalopathy may
help improve patient care and outcomes.
METHODS: We conducted a retrospective analysis of a prospective multicenter
database. Sepsis-associated encephalopathy (SAE) was defined by a score on the
Glasgow coma scale (GCS) <15 or when features of delirium were noted.
Potentially modifiable risk factors for SAE at ICU admission and its impact on
mortality were investigated using multivariate logistic regression analysis and
Cox proportional hazard modeling, respectively.
RESULTS: We included 2513 patients with sepsis at ICU admission, of whom 1341
(53%) had sepsis-associated encephalopathy. After adjusting for baseline
characteristics, site of infection, and type of admission, the following factors
remained independently associated with sepsis-associated encephalopathy: acute
renal failure [adjusted odds ratio (aOR) = 1.41, 95% confidence interval (CI)
1.19-1.67], hypoglycemia <3 mmol/l (aOR = 2.66, 95% CI 1.27-5.59), hyperglycemia
>10 mmol/l (aOR = 1.37, 95% CI 1.09-1.72), hypercapnia >45 mmHg (aOR = 1.91, 95%
CI 1.53-2.38), hypernatremia >145 mmol/l (aOR = 2.30, 95% CI 1.48-3.57), and
- aureus (aOR = 1.54, 95% CI 1.05-2.25). Sepsis-associated encephalopathy was
associated with higher mortality, higher use of ICU resources, and longer
hospital stay. After adjusting for age, comorbidities, year of admission, and
non-neurological SOFA score, even mild alteration of mental status (i.e., a
score on the GCS of 13-14) remained independently associated with mortality
(adjusted hazard ratio = 1.38, 95% CI 1.09-1.76).
CONCLUSIONS: Acute renal failure and common metabolic disturbances represent
potentially modifiable factors contributing to sepsis-associated encephalopathy.
However, a true causal relationship has yet to be demonstrated. Our study
confirms the prognostic significance of mild alteration of mental status in
patients with sepsis.
DOI: 10.1007/s00134-017-4807-z
PMID: 28466149 [Indexed for MEDLINE]
Persistent lymphopenia is a risk factor for ICU-acquired infections and for
death in ICU patients with sustained hypotension at admission.
Adrie C(1)(2), Lugosi M(3), Sonneville R(4), Souweine B(5), Ruckly S(6), Cartier
JC(3), Garrouste-Orgeas M(7), Schwebel C(3), Timsit JF(4)(6); OUTCOMEREA study
group.
BACKGROUND: Severely ill patients might develop an alteration of their immune
system called post-aggressive immunosuppression. We sought to assess the risk of
ICU-acquired infection and of mortality according to the absolute lymphocyte
count at ICU admission and its changes over 3 days.
METHODS: Adults in ICU for at least 3 days with a shock or persistent low blood
pressure were extracted from a French ICU database and included. We evaluated
the impact of the absolute lymphocyte count at baseline and its change at day 3
on the incidence of ICU-acquired infection and on the 28-day mortality rate. We
categorized lymphocytes in 4 groups: above 1.5 × 103 cells/µL; between 1 and 1.5
× 103 cells/µL; between 0.5 and 1 × 103 cells/µL; and below 0.5 × 103 cells/µL.
RESULTS: A total of 753 patients were included. The median lymphocyte count was
0.8 × 103 cells/µL [0.51-1.29]. A total of 174 (23%) patients developed
infections; the 28-day mortality rate was 21% (161/753). Lymphopenia at
admission was associated with ICU-acquired infection (p < 0.001) but not with
28-day mortality. Independently of baseline lymphocyte count, the absence of
lymphocyte count increase at day 3 was associated with ICU-acquired infection
(sub-distribution hazard ratio sHR: 1.37 [1.12-1.67], p = 0.002) and with 28-day
mortality (sHR: 1.67 [1.37-2.03], p < 0.0001).
CONCLUSION: Lymphopenia at ICU admission and its persistence at day 3 were
associated with an increased risk of ICU-acquired infection, while only
persisting lymphopenia predicted increased 28-day mortality. The lymphocyte
count at ICU admission and at day 3 could be used as a simple and reproductive
marker of post-aggressive immunosuppression.
DOI: 10.1186/s13613-017-0242-0
PMCID: PMC5355405
PMID: 28303547
Attributable mortality of ICU-acquired bloodstream infections: Impact of the
source, causative micro-organism, resistance profile and antimicrobial therapy.
Adrie C(1), Garrouste-Orgeas M(2), Ibn Essaied W(3), Schwebel C(4), Darmon M(5),
Mourvillier B(6), Ruckly S(7), Dumenil AS(8), Kallel H(9), Argaud L(10),
Marcotte G(11), Barbier F(12), Laurent V(13), Goldgran-Toledano D(14), Clec'h
C(15), Azoulay E(16), Souweine B(17), Timsit JF(6); OUTCOMEREA Study Group*.
Collaborators: Timsit JF(18), Azoulay E(19), Cohen Y(20), Garrouste-Orgeas
M(21), Soufir L(21), Le Monnier A(22), Zahar JR(23), Adrie C(24), Darmon M(25),
Alberti C(26), Clec'h C(20), Timsit JF(27), Bailly S(28), Ruckly S(29), Pommier
C(29), Ifn Essaeid W(30), Vannieuwenhuyze A(30), Allaouchiche B(31),
Ara-Somohano C(32), Argaud L(33), Barbier F(34), Bedos JP(35), Bonadona A(32),
Borel AL(36), Bornstain C(37), Bouadma L(38), Boyer A(39), Colin JP(40), Dumenil
AS(41), Gros A(35), Hamidfar-Roy R(42), Haouache H(43), Jamali S(40), Kallel
H(44), Marcotte G(31), Lautrette A(45), Laplace C(46), Misset B(21), Montesino
L(47), Mourvillier B(47), Misset B(21), Lacave G(35), Lemiale V(19), Laurent
V(35), Marriotte E(47), Planquette B(35), Reignier J(48), Sonneville R(47),
Souweine B(45), Schwebel C(32), Troché G(35), Thuong M(49), Goldgran-Toledano
D(50), Vantalon E(21), Tournegros C, Ferrand L, Kaddour N, Berthe B, Mellouk K,
Letrou S, Théodose I, Fournier J, Deiler V.
OBJECTIVES: ICU-acquired bloodstream infection (ICUBSI) in Intensive Care unit
(ICU) is still associated with a high mortality rate. The increase of
antimicrobial drug resistance makes its treatment increasingly challenging.
METHODS: We analyzed 571 ICU-BSI occurring amongst 10,734 patients who were
prospectively included in the Outcomerea Database and who stayed at least 4 days
in ICU. The hazard ratio of death associated with ICU-BSI was estimated using a
multivariate Cox model adjusted on case mix, patient severity and daily SOFA.
RESULTS: ICU-BSI was associated with increased mortality (HR, 1.40; 95% CI,
1.16-1.69; p = 0.0004). The relative increase in the risk of death was 130% (HR,
2.3; 95% CI, 1.8-3.0) when initial antimicrobial agents within a day of ICU-BSI
onset were not adequate, versus only 20% (HR, 1.2; 95% CI, 0.9-1.5) when an
adequate therapy was started within a day. The adjusted hazard ratio of death
was significant overall, and even higher when the ICU-BSI source was pneumonia
or unknown origin. When treated with appropriate antimicrobial agents, the death
risk increase was similar for ICU-BSI due to multidrug resistant pathogens or
susceptible ones. Interestingly, combination therapy with a fluoroquinolone was
associated with more favorable outcome than monotherapy, whereas combination
with aminoglycoside was associated with similar mortality than monotherapy.
CONCLUSIONS: ICU-BSI was associated with a 40% increase in the risk of 30-day
mortality, particularly if the early antimicrobial therapy was not adequate.
Adequacy of antimicrobial therapy, but not pathogen resistance pattern, impacted
attributable mortality.
Copyright © 2016 The British Infection Association. Published by Elsevier Ltd.
All rights reserved.
DOI: 10.1016/j.jinf.2016.11.001
PMID: 27838521